Healthcare Provider Details

I. General information

NPI: 1295210441
Provider Name (Legal Business Name): AMANDA ROESLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 SCHOOL LN
WILMINGTON DE
19808-6030
US

IV. Provider business mailing address

37 N 3RD ST APT 3F
PHILADELPHIA PA
19106-4500
US

V. Phone/Fax

Practice location:
  • Phone: 302-995-5608
  • Fax:
Mailing address:
  • Phone: 856-369-5783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number96044
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: